Arch Dis Child: first published as 10.1136/adc.51.7.507 on 1 July 1976. Downloaded from Archives of Disease in Childhood, 1976, 51, 507. Association of cystic fibrosis with allergy J. 0. WARNER, B. W. TAYLOR, A. P. NORMAN, and J. F. SOOTHILL From the Hospital for Sick Children, London Warner, J. O., Taylor, B. W., Norman, A. P., and Soothill, J. F. (1976). Archives of Disease in Childhood, 51, 507. Association of cystic fibrosis with allergy. Immediate skin hypersensitivity to various inhalant allergens was present in 59°% of 123 children with cystic fibrosis (CF), a much higher percentage than in the general population. This is consistent with the idea that atopy arises as a result of impaired handling of antigen at mucosal surfaces. The allergic CF children had more chest infections, a worse chest x-ray appearance, and lower peak expiratory flow rates. Allergic diseases were also frequent in the CF obligate heterozygotes (32% of mothers and 26 % of fathers). It is suggested that the heterozygotes may also have a mucosal abnormality resulting in defective antigen handling. The suggestion that atopy may result from exces- TABLE I sive stimulation of the IgE-producing cells because Clinical presentation of 123 children at initial of failure of antigen exclusion at mucosal surfaces diagnosis of cystic fibrosis related to subsequent skin- is supported by the observation that much infantile test findings atopy is preceded by IgA deficiency (Taylor et al., 1973). This is consistent with the view that anti- Skin test gen exclusion is, in part, dependent on immune Presentation Total reactions. However, it is possible that other Positive Negative abnormalities of mucosal function might have a Chest, with or similar effect. We have therefore undertaken a without bowel symptoms 66 42 24 study of allergy in cystic fibrosis (CF). This paper Meconium ileus 25 15 10 http://adc.bmj.com/ reports the first results of an on-going project. Bowel symptoms alone 25 12 13 Sib screen 6 3 3 Patients and methods Nasal polyps 1 1 0 The 123 children with CF studied were sequential attenders at the CF clinic of this hospital, which caters Total 123 73 50 for about 150 patients. Those excluded from assess- ment either did not wish to be included or were not available at the time of study. There were 45 girls and greater than 3 mm diameter. No patients reacted to on October 2, 2021 by guest. Protected copyright. 78 boys whose ages ranged from 4 months to 171 years. the control solution. The diagnosis of CF was established by the clinical Also noted were the latest chest x-ray findings (PA history and a sweat sodium concentration greater than and lateral), using an evaluation score (Chrispin and 70 mEq/l. The range of clinical presentations (Table Norman, 1974), peak expiratory flow rates measured I) was fairly characteristic of the condition. with a Wright peak flow meter; and thoracic gas volumes Parents were questioned in detail about their child's measured by total body plethysmography within the respiratory symptoms and the occurrence of allergic previous 6 months. phenomena. Family histories of atopic diseases were also recorded. The information was recorded on a Results standard questionnaire. All children were examined 73 had immediate and skin-prick tested, either on the forearms or back, Of the 123 CF children (59%) with 12 Bencard skin test antigens (Table II) and a skin sensitivity to one or more allergens. The control solution. Reactions were examined at 20 proportion of positive reactions was similar in boys minutes and were considered positive when a flare and girls (Table III). The mean age of presenta- reaction was greater than 5 mm diameter and a wheal tion was similar in the two groups (1 57 and 1-64 years respectively), though the age at the time of Received 24 October 1975. testing was older in the allergic group (8*9 com- 507 Arch Dis Child: first published as 10.1136/adc.51.7.507 on 1 July 1976. Downloaded from 508 Warner, Taylor, Norman, and Soothill TABLE II Skin sensitivities of allergic CF patients compared with those of allergy clinic patients X2 test for Allergic CF patients Allergy clinic patients significance Allergens of grotup differences No. positive No. negative % positive No. positive No. negative % positive P House dust extract 24 49 33 194 113 63 <0 001 Dermatophagoides pteronvssinus 18 55 25 222 85 72 <0 001 Dermatophagoidesfarinae 17 56 23 224 83 73 <0 001 Feathers 16 57 22 69 217 24 NS >0 05 Cat fur 12 61 16 89 64 58 <0 001 Dog hair 10 63 14 56 94 37 <0 001 Whole egg 3 70 4 10 83 11 NS >0 05 Milk 7 66 10 14 80 15 NS >0 *05 Timothy grass 41 32 56 - - - Rye grass 39 34 53 - - - - Aspergillus fumigatus 41 32 56 5 25 17 <0*001 Cladosporium 23 50 31 35 223 14 <0*001 TABLE III TABLE IV Skin reactivity related to sex in CF patients Possible allergic symptoms of CF patients related to shin reactivity Skin test positive Skin test negative Skin test No. 0 No. % Allergic symptoms Positive Negative Boys 44 56 34 44 Girls 29 64 16 36 Wheezing with infections 36 18 Wheezing at other times 19 9 Total 73 59 50 41 Hay fever 16* 4* Urticaria 13 5 Eczema 10 4 Perennial rhinitis 11 12 Drug allergy 6 4 pared with 7 9 years). The incidence of positive Food allery 2 6 reactions to each of the allergens is compared in Nasal polyps 3 5 http://adc.bmj.com/ Table II with the incidence in children attending the hospital allergy clinic during 1973 and 1974, *Significant difference; P <0 05. mainly for asthma and allergic rhinitis. The incidence of reactions to house dust and mite, cat intervals in the outpatient clinic did not obviously fur, and dog hair was significantly lower and the differ, and Pseudomonas aeruginosa was isolated incidence ofreactions to mould allergens significant- repeatedly from the sputum of similar numbers of ly higher in the CF patients who reacted to any cases in each group. antigen. Three patients reacted to 11 or 12 of the All the patients with the most abnormal chest on October 2, 2021 by guest. Protected copyright. antigens, 16 reacted to only 1, and 41 reacted to one x-ray findings were allergic (Fig. 1). Since there or both moulds-8 of them reacting to mould anti- are many ties at the lower levels of abnormality gen alone. ranking tests are insensitive in testing the difference, The range of possible allergic symptoms in but if we apply a x2 test for patients with chest relation to skin reactivity (Table IV) occurred x-ray scores > or <15 the difference is significant frequently in both groups; more hay fever sufferers (Table V). were skin-test positive. More of the CF allergic Figs. 2 and 3 show the distributions of peak cases presented with chest symptoms (Table I), expiratory flow (PEF) and thoracic gas volume though the difference was not significant, whereas (TGV) by height (cm) for the allergic and non- for other presentations the incidences were equal. allergic patients. There is a tendency for all CF A high proportion of the allergic group had re- patients to have lung overinflation (high TGV), be- peated (more than two) severe chest infections coming greater with increasing height (that is, age) requiring hospital admission during the period of with no obvious difference between the two groups. medical supervision (Table V). Bacteria isolated The PEFs have fallen predominantly within the from serial sputum specimens taken at two-monthly normal range, but significantly more allergic patients Arch Dis Child: first published as 10.1136/adc.51.7.507 on 1 July 1976. Downloaded from Association of cysticfibrosis with allergy 509 TABLE V Skin reactivity related to various factors Breast fed CXR score Pseudomonas TGV >2 SD PEF >2 SD > 2 Severe chest No severe chest >3/12 > 15 in sputum above mean below mean infections infections Skin test positive 12 14 36 23 11 37 6 Skin test negative 4 3 19 10 1 21 19 X2 1-87 4-33 1-54 0-58 4-82 11 08 P value NS <0 05 NS NS <0 05 <0 001 CXR = chest x ray. TGV = thoracic gas volume. PEF peak expiratory flow. 18- 500- 16- 0J Skin test negative 14- * Skin test positive Aller( c 12 *Nona31lIle rgic 0 8 400- E 00 2 4 b 8 10 12 14 16 18 20 22 24 26 28 30 .' 300 Chest x-roy score - FIG. l.-Chest x-ray scores in skin-test positive and skin- LU.1 test negative patients. 200- had PEF values below the 3rd centile. Breast- feeding made no difference to the incidence of allergy, more children being breast-fed for 3 months http://adc.bmj.com/ or more in the allergic group (Table V), though we do not know how many received cows' milk supple- 100- 8 ments during the immediate postnatal period. A history of allergic disease was found among the 40 first-degree relatives in 65 of 114 families investigat- 40 ------ ed (9 families had 2 CF children). Out of the 80 100 I5 200 obligate heterozygotes 36 of 114 (32%) mothers Height (cm) 30 of 114 (26%) fathers had a history of asthma, on October 2, 2021 by guest. Protected copyright. and FIG. 2.-Peak expiratory flow rates (PEF) plotted against hay fever, or urticaria. height for allergic and nonallergic CF patients (expected mean and 2 SD lines indicated).